The Physiotherapy Management of Postoperative Mid-shaft Clavicular Fracture With Brachial Plexus Injury: A Case Report

Traumatic brachial plexus injury (BPI) is a debilitating condition predominantly affecting young males, often resulting from traction or direct injuries. Due to the complicated neuronal network, the damage is often classified as preganglionic or postganglionic injuries. It includes upper-limb mobility impairments as well as reduced muscular strength and sensitivity. We discuss a case of a 30-year-old female who suffered a displaced mid-shaft clavicular fracture and BPI after a road traffic collision. The patient experienced significant pain, restricted movement, and sensory and motor loss in her left arm. Imaging studies revealed additional complications, including epidural collection and pseudomeningoceles. She underwent open reduction and internal fixation of the clavicle, followed by a structured rehabilitation program focusing on pain management, muscle re-education, and functional recovery. This case highlights the complexity of managing clavicular fractures with concurrent BPI, requiring a multidisciplinary approach involving imaging, surgical intervention, and comprehensive physiotherapy for optimal recovery and functional restoration. Rehabilitation strategies were employed to address the diverse symptoms, including multi-sensory strategies, sensory re-education, graded motor imagery rehabilitation, and gradual restoration of upper extremity (UE) range, strength, and endurance and to develop neuromuscular control. Effective management of clavicular fractures with BPI requires early diagnosis, surgical intervention, and structured rehabilitation to improve functional outcomes and quality of life.


Introduction
Brachial plexus injury (BPI) is a devastating condition that predominantly impacts young males in their prime working years, resulting in a massive socioeconomic burden [1].Based on the mechanism of injury, BPI can be classified into two main types: traction injuries leading to avulsion or rupture of cervical roots, and direct injuries affecting the brachial plexus trunks, cords, or nerves [2].BPI is a rare and complex issue, with very few cases documented in the literature [3].The patient evaluation involves a detailed examination of motor and sensory functions in the upper extremities (UEs), along with the use of radiological and electrodiagnostic studies.Conservative management tends to be successful, resulting in recovery over several months [4].
Clavicle fractures, often caused by falls, can cause pain and break sound.Physical examination may show edema, soreness, or deformities.Neurovascular exams are crucial due to the close proximity of the subclavian arteries and brachial plexus.A lung examination is also necessary for lung apex damage [5].In approximately 1-3% of cases involving clavicle fractures, patients may encounter acute complications.These complications often manifest as neurovascular injuries, encompassing damage to the subclavian vein and/or artery injury, brachial plexus, thrombosis, or stenosis [6].Additionally, lung injuries or pneumothorax, as well as related musculoskeletal injuries, are also observed as potential complications [7].
BPI is a prevalent condition among males aged 15-25 years, with traffic accidents accounting for 70% of traumatic BPI cases.These injuries often involve multiple damages, such as supraclavicular plexus lesions, lower plexus root avulsions, and chronic pain [8].The second most common cause of BPI is ballistic trauma, which leads to neuropraxia.Such injuries significantly impair daily activities and result in long-lasting debility.Both the patient and their caregivers may experience psychosocial and socioeconomic burdens.
The spinal nerves are formed by the convergence of dorsal and ventral rootlets from the spinal cord, and injuries occurring before the dorsal root ganglion are called "preganglionic," while those occurring after it are termed "postganglionic."Differentiating between preganglionic and postganglionic BPIs is key for determining the appropriate treatment and prognosis.Early surgical intervention is necessary for spontaneous recovery after preganglionic injuries [9].BPI is an uncommon occurrence following adult clavicle fractures, with only a limited number of cases in the medical literature.The majority of these cases involve brachial plexus compression resulting from fracture displacement or hypertrophic callus formation.
The need for rehabilitation following BPI is on the rise as a result of advancements in diagnosis and surgical procedures.Treatment approaches differ based on the intricate nature of the brachial plexus, the location of the injury, and its underlying causes [10].Neuromuscular electrical stimulation (NMES) is a promising tool for the rehabilitation of peripheral nerve injuries and their functional recovery.However, research is scarce on acute traumatic BPIs in the polytrauma population, particularly in younger males with multiple-site trauma [11].
As Major Trauma Centres continue to expand, the demand for rehabilitation services for polytrauma patients with BPIs outside specialized peripheral nerve centers is on the rise.Unfortunately, there is currently no nationally agreed-upon rehabilitation pathway for complex BPIs in the polytrauma population, potentially compromising their overall function and quality of life [12].Research is centered on various interventions such as exercise, sensory training, neuroelectromagnetic stimulation, acupuncture, massage therapy, hydrotherapy, phototherapy, and neural stem cell therapy [13].

Patient information
A 30-year-old female presented to the emergency department following a road traffic collision.The patient reported a single episode of vomiting, neck pain, left shoulder pain, an inability to use her left arm, and complaints of chest injury.Upon admission, she exhibited irritability and transient loss of consciousness with a Glasgow Coma Scale (GCS) score of 10.

Investigation
A CT brain scan was performed immediately, revealing no abnormalities.Radiographs of the chest showed b/l pleural effusion and the left UE identified a displaced mid-shaft clavicular fracture and shoulder subluxation.Before surgery, an MRI was conducted to evaluate potential complications, revealing epidural collection at C4, C5, and C6 suggestive of pseudomeningoceles and preganglionic nerve injury.The patient was subsequently recommended for open reduction and internal fixation of the clavicular fracture.After surgery, nerve conduction velocity testing (NCV) was done, which pointed to a left global brachial plexus lesion at the postganglionic proximal upper trunk and preganglionic C7, C8-T1 root level lesion.

Clinical examination
After obtaining verbal consent, a comprehensive physical examination was conducted as the patient was conscious, cooperative, and well-oriented to time, place, and person.The examination revealed normal vital signs with no other systemic abnormalities.Local examination showed an abrasion on the left side of the chest and a contusion with swelling over the left supraclavicular region.Palpation indicated grade 3 tenderness.The pain was sudden in onset, exacerbated by UE movements, and alleviated by rest and medications.The pain was located at the back of the neck, anterior aspect of the clavicle, and lateral aspect of the arm, with no temporal variations, and was described as dull-aching.The patient also exhibited paraspinal muscle spasms.Her range of motion was painful and incomplete.Sensory examination revealed loss of superficial as well as deep sensation over left arm.Reflex assessment was also done, which is shown in Table 1.

Postural examination
With the patient's verbal consent, a comprehensive postural assessment was conducted in three views: anterior, lateral, and posterior.

Anterior and Posterior View
The left shoulder was slightly depressed while the remaining body segments were aligned in a neutral position as shown in Figure 1A.The left shoulder appeared slightly depressed, with a slight dipping of the left pelvis.The right hip exhibited slight internal rotation as shown in Figure 1B.

FIGURE 1: Anterior and lateral views of postural evaluation of the patient
A: anterior view evaluation; B: lateral view evaluation

Lateral View
A forward neck posture was observed, along with a positive sulcus sign on the left shoulder.Additionally, a slight anterior pelvic tilt was noted as shown in Figure 2.

FIGURE 2: Images showing posterior views of postural evaluation
A: posterior view of posture assessment; B: dipping of the right humeral head, i.e., positive sulcus sign is shown

Diagnostic assessment
The patient underwent a diagnostic assessment, including a chest X-ray that revealed mild blunting of the left costophrenic angle with mild pleural effusion/hemothorax and linear displaced fracture of the middle 1/3rd of the clavicle as shown in Figure 3. Furthermore, a radiograph of the UE was taken postoperatively, showing internal fixation of the fracture with shoulder subluxation as shown in Figure 4. Subsequently, an MRI scan of the cervical spine was conducted, revealing epidural collection at the left side of C4, C5, and C6 levels suggestive of pseudomeningocele, preganglionic nerve injury as shown in Figure 5.

Therapeutic interventions
In phase 1 (zero to four weeks) of the intervention for a patient, proprioceptive neuromuscular facilitation (PNF) techniques are employed to promote muscle strength, flexibility, and coordination.This initial phase focuses on gentle, assisted movements to enhance proprioception and neuromuscular control.The techniques include rhythmic initiation, where movements are guided passively before gradually incorporating active participation, and alternating isometrics, which involve resistance applied in various directions to improve stability.The goal during this phase is to facilitate neuromuscular re-education, reduce muscle stiffness, and lay the groundwork for more intensive therapy in subsequent phases, all the while ensuring the patient's comfort and preventing further injury (Table 2).

Goals Intervention Rationale Dosage
To develop strategies to manage and cope with pain or discomfort

Patient and caregiver education
Educate the patient about his condition, potential complications, and preventive strategies, as well as the physiotherapy protocol to be followed Immobilization in a hemi-sling using Velpeau bandaging involves positioning the injured arm across the chest with the elbow bent at a 90-degree angle.A triangular bandage is placed over the arm, with the ends tied behind the neck to support the arm.A roller bandage is then applied in a figure-of-eight pattern, starting at the elbow, wrapping around the back to the opposite shoulder, and then around the chest, ensuring each layer overlaps.The bandage is secured with a safety pin or tape, ensuring the arm is snugly but comfortably immobilized, with regular checks for proper circulation as seen in Figure 6.

FIGURE 6: Immobilization in hemi-sling via Velpeau bandaging
In phase 2 (four to eight weeks) of the therapeutic intervention for a patient, the focus shifts to enhancing muscle strength, endurance, and functional mobility.Building on the foundational improvements from Phase 1, more active and resistive exercises are introduced.Techniques such as dynamic reversals, where the patient actively moves through a range of motion against resistance, and contract-relax methods to improve flexibility and muscle activation are emphasized.Weight-bearing exercises and more complex movement patterns are gradually incorporated to promote functional strength and stability.The intensity of exercises is increased, while still ensuring proper technique and patient safety.The goal is to progress towards more functional activities, preparing the patient for advanced phases of rehabilitation that target specific daily tasks and overall independence (Table 3).In Phase 3 (8-12 weeks) of the therapeutic intervention for a patient, the focus is on advanced strengthening, coordination, and functional training to further enhance the patient's capabilities and independence.During this phase, exercises are more challenging and closely mimic daily activities.Highintensity resistance training, balance exercises, and advanced PNF patterns are employed to refine motor control and stability.Functional activities such as gait training, stair climbing, and simulated tasks relevant to the patient's lifestyle are integrated to promote the practical application of skills.The intensity and complexity of exercises are tailored to the patient's progress, ensuring continual improvement while minimizing the risk of injury.The goal is to achieve a high level of functional independence and prepare the patient for a return to normal daily activities (Table 4).

Goals Intervention Rationale Dosage
To regain strength and neuromuscular

Outcomes
The outcome measure evaluation of the patient is shown in Table 5.This case highlights the complexity of managing a displaced mid-shaft clavicular fracture with concurrent BPI following a road traffic accident.The multidisciplinary approach, including timely imaging, surgical intervention, and comprehensive physiotherapy, is crucial for optimal recovery and functional restoration.

Outcomes
Clavicle fractures can rarely lead to compression of the brachial plexus.On the other hand, traumatic elongations of the brachial plexus are more commonly observed, often due to high-energy traumas.These elongations frequently coincide with fractures of the cervical spine, ribs, humerus, scapula, and clavicle.
Compression of the brachial plexus typically leads to neurapraxia without axonotmesis, resulting in secondary thoracic outlet syndrome that often requires surgical intervention.Symptoms may manifest as pain, weakness, rapid fatigue of shoulder girdle muscles, and numbness or paresthesia in the arm and fingers, exacerbated by repetitive shoulder movements.Surgical options for treating late neurologic symptomatic clavicle fractures include first rib resection, scalenectomy, clavicle resection, costoclavicular space decompression, and corrective osteotomy with internal fixation [17].
Gushikem et al. showed that the application of neurophysiotherapy serves to prevent the occurrence of joint stiffness, muscle atrophy, and contractures, while simultaneously reinstating the complete range of motion and improving the overall quality of life.Traumatic BPIs, commonly caused by road traffic crashes, often require surgical intervention for repair.These intricate injuries necessitate long-term and intensive therapeutic interventions and individuals affected by such injuries frequently face challenges in carrying out daily tasks and returning to work, particularly if their occupation involves manual labor [18].In a similar study, Deodhe et al. heightened challenges in carrying out everyday activities as UE function declined.Following a six-week intervention involving PNF and functional electrical stimulation (FES), a notable enhancement in UE function was noted.Consequently, the PNF and FES proved to be beneficial in improving functional mobility after traumatic BPI [19].Dave et al. found that the combination of electrical stimulation and PNF therapy was more successful in rehabilitating BPIs than individual therapies on their own [20].

Conclusions
This report underscores the complexity and challenges of managing a displaced mid-shaft clavicular fracture with a concurrent BPI after a road traffic accident.The effective management of such injuries requires a multidisciplinary approach, including timely imaging, surgical intervention, and comprehensive physiotherapy.Early intervention helps to prevent secondary complications such as muscle atrophy and joint stiffness.This approach is crucial for optimal recovery and functional restoration.In rehabilitation programs, particularly those incorporating electrical stimulation and PNF techniques, graded motor imagery plays a vital role in improving functional mobility and overall quality of life.Early diagnosis, appropriate surgical intervention, and a structured rehabilitation plan are essential for ensuring the best functional outcomes and enhancing the patient's ability to return to daily activities and work.

FIGURE 4 :
FIGURE 4: Postoperative radiograph of the left shoulder in the anteroposterior view Red arrow: internal fixation of the clavicle fracture with plate osteosynthesis.Green arrow: subluxation of the left shoulder joint

FIGURE 5 :
FIGURE 5: MRI of brachial plexus providing an impression of preganglionic nerve injury MRI: magnetic resonance imaging